Transcript Headache & Dizziness: Emergency Setting

Headache & Dizziness:
Emergency Setting
Ma. Cristina Z. Macrohon, MD, MPH, FPNA
General Neurology and Stroke
OBJECTIVES:
 Focus evaluation of Headache and
Dizzinesss in an emergency situation
 Differential diagnoses
 Immediate management
HEADACHE
All aches and pains located in the
head; discomfort in the region of
the cranial vault.
The Assessment
 Quality
 Severity
 Location
 Mode of onset
 Time-intensity curve
 Duration
 Associated Factors
• Dull, aching, sharply localized;
pricking, stinging; tightness,
pressure, bursting, sharpness,
or stabbing; throbbing
• Degree; propensity to disturb
sleep
• Paranasal sinuses, Vertex,
biparietal, frontotemporal,
occipito-nuchal region,
supraorbital, infraorbital, ears,
etc.
• Temporal profile
• Biologic Events, precipitating,
aggravating, and relieving factors
CLUES TO DIAGNOSIS
1.
2.
3.
4.
5.
6.
7.
Site
Age and Sex
Clinical Characteristics
Diurnal Pattern
Life Profile
Provoking Factors
Associated Features
International Classification of Headache
Disorders
1. Migraine
2. Tension type
headache
3. Cluster headache
and other trigeminal
autonomic
cephalalgias
4. Other primary
headaches
5. Headache attributed to
head and/or neck trauma
6. Headache attributed to
cranial or cervical
vascular disorders
7. Headache attributed to
non-vascular intracranial
disorder
8. Headache attributed
to a substance or its
withdrawal
International Classification of Headache
Disorders
9. Headache attributed to
infection
10. Headache attributed to
disorders of hemoestasis
11. Headache or facial pain
attributed to disorder of
cranium, neck, eyes, ears,
nose, sinuses, teeth, mouth or
other facial or cranial
structures
11. Headache or facial pain
attributed to disorder of
cranium,neck, eyes, ears,
nose, sinuses, teeth, mouth or
other facial or cranial
structures
12. Headache attributed to
psychiatric disorders
13. Cranial neuralgias and central
causes of facial pain
14. Other headache, cranial
neuralgia, central or primary
facial pain
Pain-sensitive structures in the head
Intracranial Structures
• Venous sinuses and
afferent veins
• Arteries of the dura mater
and pia-arachnoid
• Arteries of the base of the
brain and their major
branches
• Parts of the dura mater
near the large vessels
Pain-sensitive structures in the head
Extracranial Structures
• Skin
• Muscles
• Periosteum of the skull
• Mucosa
• Extracranial arteries
• Delicate structures of
the eye, ear, nasal
cavities and sinuses
Nerves
• Trigeminal
• Facial
• Glossopharyngeal
• Vagus
• Upper three cervical
roots
Non-sensitive structures
􀂑 Skull
􀂑 Pia-arachnoid and dura over the convexity
of the brain
􀂑Brain parenchyma
􀂑 Ependyma
􀂑 Choroid plexuses
CLUES TO DIAGNOSIS
1.
2.
3.
4.
5.
6.
7.
Site
Age and Sex
Clinical Characteristics
Diurnal Pattern
Life Profile
Provoking Factors
Associated Features
1. Migraine without Aura
SITE: - Frontotemporal Uni or bilateral
AGE & SEX: Adolescents, young to middle
aged adults, children, women
CHARACTER: Throbbing, dull ache and
generalized, scalp sensitive
PATTERN: Upon awakening or later in the
day
DURATION: 4-24 H, sometimes longer
1. Migraine without Aura
LIFE PROFILE: Irregular intervals, weeks to
months; tends to decrease in middle age
and during pregnancy
PROVOKING FACTORS: Bright light, noise,
tension, alcohol; relieved by darkness and
sleep
ASSOCIATED FEATURES: Nausea and
vomiting
1. Migraine without Aura
• TREATMENT:
– Ergotamine; sumatriptan, NSAIDS
• PREVENTION:
– Propanolol or amitriptyline
2. Migraine with Aura
ASSOCIATED FEATURES:
Scintillating lights, visual loss, and
scotomas;
unilateral
paresthesias,
weakness, dysphasia, vertigo, rarely
confusion
AURAS
Scintillating Scotoma
3. Cluster Headache
SITE: - Orbitotemporal; Unilateral
AGE & SEX: Adolescent and adult males
(90%)
CHARACTER: Intense, nonthrobbing
PATTERN: Nocturnal, 1-2H after falling
asleep, occasionally diurnal
3. Cluster Headache
LIFE PROFILE: Nightly or daily for several
weeks to months; Recurrence after many
months or years
PROVOKING FACTORS: alcohol
ASSOCIATED FEATURES: Lacrimation,
stuffed nostril, rhinorrhea, injected
conjunctivum, ptosis
3. Cluster Headache
• TREATMENT:
– Ergotamine before anticipated attack;
Oxygen; sumatriptan
– Methysergide, corticosteroids, verapamil,
valproate, and lithium in recalcitrant cases
4. Tension Headaches
SITE: Generalized Mainly adults, both sexes
CHARACTER: Pressure, tightness, aching
PATTERN: Continuous, variable intensity
DURATION: days
AGE & SEX: weeks, or months
4. Tension Headache
LIFE PROFILE: one or more periods of
months to years
PROVOKING FACTORS: Fatigue and
nervous strain
ASSOCIATED FEATURES: Depression,
worry, anxiety
TREATMENT: Antianxiety and antidepressant drugs
5. Meningeal Irritation (Meningitis or SAH)
SITE: Generalized, or bioccipital or bifrontal
AGE & SEX: Any
CHARACTER: Intense, steady deep pain,
worse in neck
PATTERN: Rapid evolution – minutes to
hours
LIFE PROFILE – single episode
5. Meningeal Irritation (Meningitis or SAH)
PROVOKING FACTORS: none
ASSOCIATED FEATURES: Neck stiff on
forward bending, kernig and brudzinski
signs
TREATMENT: Antianxiety and antidepressant drugs
6. Brain Tumor
SITE: Unilateral or Generalized
AGE & SEX: Any
CHARACTER: Variable Intensity, May
awaken patient, steady pain
PATTERN: worse in a.m. increasing severity,
lasts minutes to hours
LIFE PROFILE – once in a lifetime: weeks
to months
6. Brain Tumor
PROVOKING FACTORS: none; position
ASSOCIATED FEATURES: Papilledema,
vomiting, impaired mentation, seizures,
focal signs
TREATMENT: Corticosteroids, Mannitol,
treatment for tumors
7. Temporal Arteritis
SITE: Unilateral or bilateral, usually temporal
AGE & SEX: over 50 years, either sex
CHARACTER: Throbbing, then persistent
aching and burning, arteries thickened and
tender
PATTERN: Intermittent then continuous
LIFE PROFILE –weeks to months
7. Temporal Arteritis
PROVOKING FACTORS: none
ASSOCIATED FEATURES: Loss of vision,
polymyalgia rheumatica, fever, weight
loss, increased sedimentation rate
TREATMENT: Corticosteroids
DIZZINESS
Refers to different sensory experiences;
rotation or whirling, nonrotatory swaying,
weakness, faintness, lightheadedness, or
unsteadiness; dizzy spells
The Vestibular Reflex System
VERTIGO VS DIZZINESS VS
PSEUDOVERTIGO
Diagnosing Vertigo
Px complaints of Dizziness
Does the px has true vertigo?
YES
YES
NO
Intake of drugs causing
vertigo?
YES
Stop medications
NO
Diagnostic work up for
lightheadedness,
presyncope, or
dysequilibrium
NO
Obtain hx, especially timing and duration,
provoking and aggravating factors, assoc
symptoms, and risk factors for CVD
Perform PE with special attention to head
and neck, cardiovascular, neurologic
systems, and provocative dx tests
Refine Differential Diagnosis
Consider MRI for possible Central
Cause: focal neurologic signs
Other laboratory or Radiologic
studies as indicated
Refer to a specialist if diagnosis is in
doubt or indicated by findings
Vertiginous Syndromes
1. Labyrinths
Neurologic Findings: None
Disorders of Equilibrium: Ipsilateral past pointing
and lateral propulsion to side of lesion
Types of Nystagmus: Horizontal or rotary to side
opposite lesion, positional and position
changing, fatigable.
Hearing: Normal or conduction of neurosensory
deafness with recruitment
Diagnostics: Caloric testing
2. Vestibular nerve and ganglia
Neurologic Findings: CN 8th and 7th palsy
Disorders of Equilibrium: Ipsilateral past
pointing and lateral propulsion to side of
lesion
Type of Nystagmus: Unidirectional positional,
Hearing: sensorineuroal deafness sometimes
Diagnostics: Radiography, CT, or Calorics
3. Cerebellopontine Angle
Neurologic Findings: Ipsilateral 5th, 7th, 9th,
10th,CN, ataxia, and increase ICP
Disorders of Equilibrium: Ataxia and falling
ipsilaterally
Type of Nystagmus: Gaze-paretic, positional,
coarser to side of lesion
Hearing: sensorineuroal deafness without
recruitment
Diagnostics: CT, MRI, calorics, BAER, CSF
4. Brainstem and Cerebellum
Neurologic Findings: Multiple CN, brainstem
tract signs, cerebellar ataxia
Disorders of Equilibrium: Ataxia present with
eyes open
Type of Nystagmus: Coarse horizontal and
vertical, gaze-paretic
Hearing: normal
Diagnostics: CT, MRI, Calorics
5. Higher Connections
Neurologic Findings: Aphasia, visual field,
hemimotor, hemisensory, and other
cerebral abnormalities, seizures
Disorders of Equilibrium: No change
Type of Nystagmus: absent
Hearing: Normal
Diagnostics: CT and EEG
PERIPHERAL VS CENTRAL VERTIGO
Feature
Nystagmus
Peripheral
Central
Combined horizontal and
torsional;inhibited by fixation of eyes
onto object;
fades after a few days; does not
change direction with gaze to either
side
Purely vertical, horizontal, or
torsional; not inhibited by fixation of
eyes onto object; may last weeks to
months; may change direction with
gaze towards
fast phase of nystagmus
Imbalance
Mild to moderate; able to walk
Severe; unable to stand still or
walk
Nausea, vomiting
May be severe
Varies
Hearing loss, tinnitus
Common
Rare
Nonauditory
neurologic symptoms
Rare
Common
Latency
Longer (up to 20 sec)
Shorter (up to 5 sec)
Meniere’s Disease
• Triad of recurrent vertigo, fluctuating
tinnitus, and deafness
• Affects both sexes equally, 5th decade of life
• Tx:
– Rest in bed
– Low salt diet + ammonium chloride + diuretics
– Cyclizine, Meclizine, and transdermal
scopolamine
– Surgery
BPPV
• Paroxysmal vertigo and nystagmus that
occur only with the assumption of certain
positions of the head.
• Last < 1 minute but recur periodically for
several days or months or years.
• TX:
– Dix-Hallpike Maneuver
– Surgery
– Medical
Vestibulopathy
• Ototoxic effects of aminoglycosides;
alcohol,
anticonvulsants,
anti-HTN,
barbiturates,
cocaine,
diuretics,
nitroglycerin,
quinine,
salicylates,
sedatives/hypnotics
• Cochlear hair cells and vestibular labyrinth
• Disequilibrium and oscillopsia;
unsteadiness of gait worse with eyes closed
Vestibular Neuronitis
• Paroxysmal and a prolonged single attack
of vertigo and by absence of tinnitus and
and deafness
• Young to middle-aged adults
• Hx of antecedent upper respiratory
infection of non-specific etiology
• Tx:
Methylprednisolone; antihistamne
drugs,
phenergan,
clonazepam,
scopolamine
Brainstem Origin
• Auditory function is nearly always spared
• Vertigo is less severe
• Nystagmus may be uni-bidirectional,
purely horizontal, vertical or rotatory,
worsened by attempted visual fixation.
• Associated CN, sensory, and motor tracts
Thank You 